More emphasis needs to be placed on the role of the Internet in CSB. (YBOP strongly believes that Internet porn addiction must be separated from "sex addiction.")

The internet facilitates sexual behaviours that an individual would never imagine engaging in offline. (Individuals who develop cybersex addiction today would rarely have become sex addicts prior to highspeed internet.)

The evidence for sex addiction/hypersexual disorder is on par with Internet Gaming Disorder (IGD), yet IGD was included in DSM-5 (section 3) while sex addiction was omitted. (YBOP views this as a political decision, not one based on science.)

Sex addiction has been kept out of the DSM because the public equates it with high profile celebrities who are using the label to justify their behavior. (Again, it is time to separate sex addiction from porn addiction.)

Griffiths believes, as YBOP does, that, "clinical evidence from those who help and treat such individuals should be given greater credence by the psychiatric community" [i.e., by the DSM and WHO].

The issue of sex addiction as a behavioural addiction has been much debated. However, there is little face validity for co-occurring behavioural addictions, and more emphasis is needed on the characteristics of the internet as these may facilitate problematic sexual behaviour.

The review by Kraus and colleagues [1] examining the empirical evidence base for classifying compulsive sexual behaviour (CSB) as a behavioural (i.e. non-substance) addiction raises many important issues and highlights many of the problems in the area, including the problems in defining CSB, and the lack of robust data from many different perspectives (epidemiological, longitudinal, neuropsychological, neurobiological, genetic, etc.). I have carried out empirical research into many different behavioural addictions (gambling, video-gaming, internet use, exercise, sex, work, etc.) and have argued that some types of problematic sexual behaviour can be classed as sex addiction, depending upon the definition of addiction used [2-5].

However, there are areas in Kraus et al.’s paper that were mentioned briefly without any critical evaluation. For instance, in the section on co-occurring psychopathology and CSB, reference is made to studies claiming that 4–20% of individuals with CSB also display disordered gambling behaviour. A comprehensive review [5] examining 11 different potentially addictive behaviours also highlighted studies claiming that sex addiction could co-occur with exercise addiction (8–12%), work addiction (28–34%) and shopping addiction (5–31%). While it is possible for an individual to be addicted to (for instance) cocaine and sex concurrently (because both behaviours can be carried out simultaneously), there is little face validity that an individual could have two or more co-occurring behavioural addictions because genuine behavioural addictions consume large amounts of time every day. My own view is that it is almost impossible for someone to be genuinely addicted to (for example) both work and sex (unless the person's work was as an actor/actress in the pornographic film industry).

The paper by Kraus et al. also makes a number of references to ‘excessive/problematic sexual behavior’ and appears to make the assumption that ‘excessive’ behaviour is bad (i.e. problematic). While CSB is typically excessive, excessive sex in itself is not necessarily problematic. Preoccupation with any behaviour in relation to addiction obviously needs to take into account the behavioural context, as this is more important in defining addictive behaviour than the amount of activity undertaken. As I have argued, the fundamental difference between healthy excessive enthusiasms and addictions is that healthy excessive enthusiasms add to life, whereas addictions take away from them [6]. The paper also appears to have an underlying assumption that empirical research from a neurobiological/genetic perspective should be treated more seriously than from a psychological perspective. Whether problematic sexual behaviour is described as CSB, sex addiction and/or hypersexual disorder, there are thousands of psychological therapists around the world who treat such disorders [7]. Consequently, clinical evidence from those who help and treat such individuals should be given greater credence by the psychiatric community.

Arguably the most important development in the field of CSB and sex addiction is how the internet is changing and facilitating CSB [2, 8, 9]. This was not mentioned until the concluding paragraph, yet research into online sex addiction (while comprising a small empirical base) has existed since the late 1990s, including sample sizes of up to almost 10 000 individuals [10-17]. In fact, there have been recent reviews of empirical data concerning online sex addiction and treatment [4, 5]. These have outlined the many specific features of the internet that may facilitate and stimulate addictive tendencies in relation to sexual behaviour (accessibility, affordability, anonymity, convenience, escape, disinhibition, etc.). The internet may also facilitate behaviours that an individual would never imagine engaging in offline (e.g. cybersexual stalking) [2, 18].

Finally, there is the issue of why Internet Gaming Disorder (IGD) was included in the DSM-5 (Section 3) but sex addiction/hypersexual disorder was not, even though the empirical base for sex addiction is arguably on a par with IGD. One of the reasons might be that the term ‘sex addiction’ is often used (and misused) by high-profile celebrities as an excuse to justify infidelity and is little more than a ‘functional attribution’ [19]. For instance, some celebrities have claimed an addiction to sex after their wives found out that they had many sexual relationships during their marriage. If their wives had not found out, I doubt whether such individuals would have claimed that they were addicted to sex. I would argue that many celebrities are in a position where they are bombarded with sexual advances from individuals and have succumbed; but how many people would not do the same thing if they had the opportunity? Sex only becomes a problem (and is pathologized) when the person is found to have been unfaithful. Such examples arguably give sex addiction a ‘bad name’, and provides a good reason for those not wanting to include such behaviour in diagnostic psychiatry texts.

Declaration of interests

The author did not receive specific funding support for this work. However, the author has received funding for a number of research projects in
the area of gambling education for youth, social responsibility in gambling and gambling treatment from the Responsibility in Gambling Trust, a charitable body who funds its research programme based on donations from the gambling industry. The author also undertakes consultancy for various gaming companies in the area of social responsibility in gambling.

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